Hospital room

Sheffield Hospitals detail improvements needed, following CQC inspection

Following a CQC inspection in March 2021, Sheffield Teaching Hospital NHS FT’s maternity service rating, changed from outstanding to inadequate. The trust’s chief nurse and chief executive have come forward to address the improvements needed, and reassure women visiting the Jessop Wing, that the service remains safe, and patients will still receive good care.

The CQC has asked the trust to act immediately on improving some of the systems and processes around risk management, where they deemed them as not being strong enough. Urgent conditions were also enforced to guarantee patient safety, requiring the trust to send updated reports on their progress, regularly.

Inspectors also raised concerns regarding staffing levels in some of the areas, viewing them as lower than the national guidance, and suggesting that some were affected by a number of vacancies. In response to the CQC’s findings, the trust has developed an action plan, as well as implementing some of the recommendations, such as recruiting more midwives.

Kirsten Major, Chief Executive, at the trust, said: “I want to assure women coming into Jessop Wing to have their babies that our maternity teams work incredibly hard every day to ensure their care is always the number one priority, and whilst we are exceptionally disappointed with the findings of the CQC report, we welcome the external scrutiny and have wasted no time in responding to the actions which have been identified as necessary.

“Many of the actions have been completed in the three months since the inspection took place. For example, our governance and risk processes are being reviewed, including how we learn from incidents and respond to data collected nationally and locally. Elements of our assessment process needed further review which we have done, and whilst our midwifery staffing levels have not declined, we are taking on board what the CQC has said and have already recruited 30 new midwives to ensure we continue to deliver the care women have come to expect from Jessop Wing.

“We clearly have some improvements to make, but we are encouraged by the feedback from families who use the service which is very positive, and reflects the commitment of our staff to provide good care, and more often than not go above and beyond what is required of them.”

The inspection involved a two-day inspection of the labour ward, two postnatal wards, antenatal ward, admission triage area, and the advanced obstetric care unit, but did not include the Neonatal Unit, Gynaecology, or Jessops Fertility services. This also involved talking to staff, and observing the care and treatment provided to patients.

Three of the five areas were established when carrying out the inspections: Safe, well led and effective. The other two areas not included – which remain unchanged - were: Responsive (rated as outstanding) and caring (rated as good).

Sarah Dronsfield, CQC’s Head of hospital inspection, said: “When we visited maternity services in the Jessop Wing at Sheffield Teaching Hospitals NHS Foundation Trust, inspectors found a service that was not providing the standard of care women should be able to expect.

“Due to the concerns, we found what needed addressing to be a priority; we have imposed urgent conditions on the trust’s registration which require immediate action in order to make sure people receive the care they are entitled to. 

“However, we also found some areas of good practice and a culture where staff felt respected, valued and supported. Staff were caring and focused on the needs of the women receiving care, and the service also promoted equality and diversity in daily work.

“The trust leadership team know what they must do to improve patient safety and we will re-inspect to ensure this happens, taking further action if needed to protect patients.”

Other areas which were positive included the medical staffing, and on-site consultant cover, both in and out of hours. Inspectors also felt that staff promoted equality and diversity, as well as infection control and cleanliness being at a good standard.

Professor Chris Morley, Chief Nurse, at the trust, said: “Whilst there is a focus quite rightly on what we need to improve I am also pleased that the inspectors found several areas of good practice and most importantly they recognised that Jessop Wing colleagues were focused on the needs of the women receiving care and that doctors, midwives and other healthcare professionals were working together as a team to benefit families.

“The teams in Jessop Wing are responding to this report with the commitment and professionalism we see every day and are completely focussed on continuing to deliver safe, good care to women and their babies.”

Some of the findings included:

  • Not enough effective systems in place for staff to have the skills, competence, knowledge and experience to safely care for women and their babies.
  • Risk assessments weren’t always updated and completed for every patient. Timely action also wasn’t taken to reduce the risks.
  • Investigations of incidents were also delayed, and lessons learned weren’t always widely shared.
  • Patient records were also stored on a variety of systems, potentially putting patients at risk.

These are the urgent conditions required by the CQC, and the Trust’s actions in response:

  • Ensure systems are put into place so that staffing is actively assessed, reviewed and escalated appropriately to prevent exposing women and babies to the risk of harm.

Trust response: Processes to match staffing levels to peaks in demand were already in place along with 24hr/7day a week escalation system prior to the inspection, but they have been further reviewed and strengthened since the visit. Any member of staff can escalate a staffing issue so that it can be resolved, and the appropriate staffing level achieved. We have a bank of 40 plus registered midwives who work flexibly to cover times when additional staffing is required. Where there is a sudden peak in demand such as the instances the CQC were aware of, the escalation process was activated to ensure the women had the appropriate level of care and minimal delays to any treatment needed.

  • Ensure systems are put in place so staff are suitably qualified, skilled and competent to care for and meet the needs of women and babies.

Trust response: Face to face training had to be paused due to the pandemic but online training still took place. However, we are looking again at how we support staff with regard to training and development as the pandemic subsides.

  • Ensure effective risk and governance systems are implemented to support safe care. Ensure risk assessments and risk management plans are completed in accordance with national guidance, and local trust policy and documented appropriately.

Trust response: A complete review of the risk and governance systems is underway, and a number of changes have already been made including faster reporting of serious incidents.

  • Improve monitoring the effectiveness of care and treatment provided to patients.

Trust response: We have implemented a maternity dashboard detailing maternity outcomes and benchmarking these against national indicators. This dashboard is shared with staff in Jessop Wing, the Trust Board and regionally with the Local Maternity and Neonatal System to ensure scrutiny of the care provided at Jessop Wing. We have also put in place additional systems to ensure women are robustly risk assessed and prioritised on arrival at the Labour Ward Assessment Unit.

  • Correct processes are in place for investigating serious incidents that reduce delays and accuracy of investigations. Improve lessons learned and the sharing of lessons learned among the whole team and the wider service.

Trust response: We have overhauled the process for identifying and investigating incidents and we have invited the National Maternity Support Team into the Jessop Wing to provide additional guidance and support to help us identify areas where we need to make improvements or take forward positive developments that have already been adopted by other maternity units or services nationally. We have already made some improvements in relation to this, such as the implementation of learning forums where the multi-disciplinary team (MDT) come together to share and discuss incident action plans. We have also introduced the HSIB (Healthcare Safety and Investigation Branch) newsletter to update staff on themes from maternity services locally and nationally that have been identified.

  • Ensure safe systems and processes to prescribe, administer, record and store medicines are in place and applied.  

Trust response: The Inspectors found that staff used systems and processes to prescribe, administer and record medicines. However, some drug fridge temperature checks were not recorded when the inspection took place and other records were not completed as expected. All staff have been reminded of the importance of checks and record keeping.

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